MEDICARE: CHRISTINE ADALINE FERGUSON LSW, LICDC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1326674052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTINE ADALINE FERGUSON LSW, LICDC LLC

Provider Business Mailing Address
First Line	:	16360 BROADWAY AVE STE 21016360
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-2555
Country	:	US
Telephone Number	:	216-865-5050
Fax Number	:

Provider Business Practice Location Address
First Line	:	16360 BROADWAY AVE STE 21016360
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-2555
Country	:	US
Telephone Number	:	216-865-5050
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	CHRISTINE A FERGUSON
Credential	:	LICDC 161363
Telephone Number	:	216-865-5050

Provider Enumeration Date	:	03/13/2020
Last Update Date	:	11/23/2022

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